Puerto Rico MacPac Fact Sheet (2021)

“Medicaid and the State Children’s Health Insurance Program (CHIP) operate in the five U.S. territories- American Samoa, the Commonwealth of the Northern Mariana Islands (CNMI), Guam, Puerto Rico, and the U.S. Virgin Islands (USVI). This fact sheet summarizes federal requirements and design features of these programs in the territories, including eligibility and enrollment, benefits, financing and spending, data and reporting, and quality and program integrity…

Delivery System
Puerto Rico is currently the only territory to use Medicaid managed care, in which the entire Medicaid population is enrolled. Managed care organizations (MCOs) provide commonwealth-wide acute, primary, specialty, and behavioral health services. They are paid risk-based capitated payments. MCOs contract with primary medical groups, which in turn create preferred provider networks (PPNs). Enrollees are auto assigned to a health plan but may switch once per year, and do not need referrals for specialists in their PPN (MACPAC 2019b).”